Online Application

Step 1 of 6 - Voluntary Self-Identification of Disability

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Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:

Blindness

Deafness

Cancer

Diabetes

Epilepsy

Autism

Cerebral Palsy

HIV/AIDS

Schizophrenia

Muscular dystrophy

Bipolar disorder

Major depression

Multiple sclerosis (MS)

Missing limbs or partially missing limbs

Post-traumatic stress disorder (PTSD)

Obsessive compulsive disorder

Impairments requiring the use of a wheelchair

Intellectual disability (previously called mental retardation)

Please select one of the options below:*

YES, I HAVE A DISABILITY (or previously had a disability)

NO, I DON'T HAVE A DISABILITY

I DON'T WISH TO ANSWER

Name*

FirstLast

Today's Date*

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

Voluntary Invitation to Self-Identify

CHCS is subject to certain governmental record keeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, CHCS invites applicants to voluntarily self-identify their race and/or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

Gender*

Male

Female

I do not wish to disclose

Race / Ethnicity*

Hispanic or Latino

White (Not Hispanic or Latino)

Black or African American (Not Hispanic or Latino)

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)

Asian (Not Hispanic or Latino)

American Indian or Alaska Native (Not Hispanic or Latino)

Two or More Races (Not Hispanic or Latino)

I DO NOT WISH TO DISCLOSE MY RACE/ETHNIC STATUS

Name*

FirstLast

Date*

Pre-Offer Invitation to Self-Identity For Protected Veterans

CHCS is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. §4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans.

These classifications are defined as follows:

A “disabled veteran” is one of the following:

a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or

a person who was discharged or released from active duty because of a service-connected disability.

A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.

An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

Please select one of the options below:*

I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE

I AM NOT A PROTECTED VETERAN

I DO NOT WISH TO DISCLOSE MY STATUS

If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are consistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended.

The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

Name*

FirstLast

Date*

On-Line Application

Community Health and Counseling Services is an equal opportunity and affirmative action employer and does not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, genetic information, protected veteran status or any other classification protected by federal, state, or local law.

This form must be completed in full. Do not leave spaces blank with a note to "See Resumé."

Date*

Basic Information

Position Applying For*

Desired Location*

Name*

FirstLast

Email*

Phone*

Address*

Street AddressCityStateZIP Code

General Background

Do you have a legal right to work in the United States?*

Yes

No

Are you 18 years of age or older?*

Yes

No

Have you ever worked for this agency before?*

Yes

No

Previous CHCS Employment Information

What position did you hold?*

Which office or location?*

Employed From*

Employed to*

Referral & Availability

Referral Source*

Newspaper

CHCS Website

Walk-In

Current Employee

When are you available for employment?*

Are you looking to work Full Time or Part Time?*

Full Time

Part Time

Both

Can you travel if the job requires it?*

Yes

No

Can you provide your own transportation?*

Yes

No

If you respond "Yes" to any of the following five questions, please provide a brief explanation in the space that appears after the questions.

Answering "Yes" to any of these questions does not necessarily disqualify you from employment. Each case is considered separately based on factors such as the job for which you are applying, the seriousness and nature of the circumstances, and the date of the occurrence(s).

1. Have you ever been the subject of a child or adult abuse allegation or complaint?*

Yes

No

2. Have you ever been convicted of a crime, including a felony, misdemeanor, or OUI?*

Yes

No

3. Is there a criminal action currently pending against you?*

Yes

No

4. Have you been the subject of any protection from abuse orders, or any other types of orders involving domestic violence within the past five years?*

Yes

No

5.Have you ever, in this state or in any other state, had a license or certificate (e.g. professional license, driver's license) revoked or suspended, or have you ever voluntarily surrendered a license or certificate?*

Yes

No

If you answered "yes" to any of the above questions, please use this space to explain.*

When listing education, if you have not completed a degree program indicate how much is completed, based on fulltime attendance (i.e., 15 credit hours per semester).

Start with your most recent position and move backward through all positions and military service for the past twenty years. You may exclude employment during high school.

Include the month and year you began and ended each position, and the average hours/week you worked. This is vital for potentially calculating a salary quote.

Furnish dates and explanations for each period of unemployment of one month or more.

You may attach a resumé for supplemental information related to volunteer work, memberships, associations, etc.

If you require more room than the space provided, please include all additional employer entries with your Resumé.

Current or Previous Employer

Employer Name*

Employer Address*

Position and Responsibilities*

Employed From*

Employed To*

Salary

Average Hours Per Week*

Supervisor's Name*

FirstLast

Supervisor's Phone*

Reason for Leaving*

May we contact this employer?*

Yes

No

Previous Employer 1

Employer Name

Employer Address

Position and Responsibilities

Employed From

Employed To

Salary

Average Hours Per Week

Supervisor's Name

FirstLast

Supervisor's Phone

Reason for Leaving

Previous Employer 2

Employer Name

Employer Address

Position and Responsibilities

Employed From

Employed To

Salary

Average Hours Per Week

Supervisor's Name

FirstLast

Supervisor's Phone

Reason for Leaving

Previous Employer 3

Employer Name

Employer Address

Position and Responsibilities

Employed From

Employed To

Salary

Average Hours Per Week

Supervisor's Name

FirstLast

Supervisor's Phone

Reason for Leaving

Previous Employer 4

Employer Name

Employer Address

Position and Responsibilities

Employed From

Employed To

Salary

Average Hours Per Week

Supervisor's Name

FirstLast

Supervisor's Phone

Reason for Leaving

High School or Equivalency

Name of School*

City and State*

Major / Focus

Number of Years Completed*

Degree Awarded ( if applicable )

Post-Secondary 1

Name of School

City and State

Major / Focus

Number of Years Completed

Degree Awarded ( if applicable )

Post-Secondary 2

Name of School

City and State

Major / Focus

Number of Years Completed

Degree Awarded ( if applicable )

Licenses & Certifications

Do you hold any licenses or certifications?

Yes

No

If yes, please list them here:*

Resume & Signature

Upload Resume*

Accepted file types: pdf, doc, docx.

Applicant's Statement

I certify that the information contained in this application is correct and complete to the best of my knowledge and belief. I understand that if I am hired, any false or misleading statement or omission of material fact may lead to dismissal.

I authorize Community Health and Counseling Services (CHCS) to verify all statements contained in this application and to make any necessary job related reference checks.

I authorize the employers, supervisors, and references provided or discovered during my application process to give CHCS any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage or injury that may result from furnishing same to CHCS.

I understand that an offer of employment may be conditioned on the results of a medical examination and background checks.

By submitting this form and dating below, I agree to the above terms and conditions.

In accordance with Federal law and USDA policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. (Not all prohibited basis apply to all programs.) To file a complaint of discrimination, write to: USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). UDSA is an equal opportunity provider and employer.